Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 899-905

Patatin-like phospholipase 3 rs738409C/G gene polymorphism in cirrhotic and hepatocellular carcinoma patients


1 Department of Clinical Pathology, National Liver Institute, Menoufia University, Menoufia, Egypt
2 Department of Medical Biochemistry, National Liver Institute, Menoufia University, Menoufia, Egypt
3 Department of Hepatology, National Liver Institute, Menoufia University, Menoufia, Egypt

Date of Submission23-Jul-2016
Date of Acceptance09-Oct-2016
Date of Web Publication15-Nov-2017

Correspondence Address:
Mohammad G Alhelbawy
Department of Clinical Pathology, Menoufia University, Shebein El kom, Menoufia Governorate, 32511
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.218270

Rights and Permissions
  Abstract 

Objective
The aim of the present study was to verify whether the rs738409C/G single nucleotide polymorphism of patatin-like phospholipase 3 (PNPLA3) gene may be associated with cirrhosis and hepatocellular carcinoma (HCC) complicating cirrhosis.
Background
PNPLA3 gene encodes a 481-amino acid protein of unknown function that belongs to the patatin-like phospholipase domain-containing family. PNPLA3 rs738409 polymorphism could be a risk factor for the development of HCC in cirrhosis patients.
Subjects and methods
This study included 50 individuals divided into three groups: group 1 (control group) included 10 apparently healthy age and sex-matched subjects; group 2 (cirrhosis group) included 20 patients diagnosed with cirrhosis and positive antihepatitis C virus (HCV) antibodies; and group 3 (HCC group) included 20 HCC patients. Liver function tests, viral markers, α-feto protein, and HCV RNA by using PCR were carried out for all participants. They were genotyped for PNPLA3 C>G polymorphism using PCR.
Results
There was significant difference in genotype distribution between the control and the HCC group [CG vs. CC: P = 0.01; odds ratio (OR)=18, 95% confidence interval (CI): 2.04–159.1, GG vs. CC: P = 002). OR showed that GG genotype was riskier than the CC 'reference group' by 18 (95% CI: 2.04–159.1). There was significant difference in the distribution of both alleles (C and G) between the two groups (P = 0.00). OR showed that G allele was riskier than C allele by 18.69 (95% CI: 3.76–92.9). There was significant difference in GG genotype distribution between the cirrhosis and the HCC group (GG vs. CC: P = 0.02; OR = 13.5, 95% CI: 1.80–101.1). OR showed that GG genotype was riskier than the CC 'reference group' by 5.06 (95% CI: 0.83–11.02). There were significant differences in the distribution of both alleles (C and G) between the two groups (P = 0.007). OR showed that G allele was riskier than C allele by 3.86 (95% CI: 1.53–9.75).
Conclusion
PNPLA3 rs738409 C>G polymorphism was associated with HCC in HCV cirrhotic patients.

Keywords: cirrhosis, hepatocellular carcinoma, PNPLA3 rs738409 C>G polymorphism


How to cite this article:
El Saeed GK, El-EdeL RH, El Said HH, Abdellateef Taha HE, Noreldin RI, Alhelbawy MG. Patatin-like phospholipase 3 rs738409C/G gene polymorphism in cirrhotic and hepatocellular carcinoma patients. Menoufia Med J 2017;30:899-905

How to cite this URL:
El Saeed GK, El-EdeL RH, El Said HH, Abdellateef Taha HE, Noreldin RI, Alhelbawy MG. Patatin-like phospholipase 3 rs738409C/G gene polymorphism in cirrhotic and hepatocellular carcinoma patients. Menoufia Med J [serial online] 2017 [cited 2019 Nov 12];30:899-905. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/899/218270


  Introduction Top


Cirrhosis is the end-stage consequence of fibrosis of liver parenchyma and defined histologically as a diffuse process in which the normal anatomical lobules are replaced by architecturally abnormal nodules separated by the fibrous tissue [1].

Cirrhosis is the 12th leading cause of death in the USA. It accounted for 29 165 deaths in 2007, with a mortality rate of 9.7/100 000 persons. Cirrhosis is a major risk factor for the development of hepatocellular carcinoma (HCC); the incidence of this malignancy tripled from 1975 to 2005 [2].

In Egypt, according to the National Cancer Institute, the incidence rate of HCC has increased sharply in the last decade [3]. The most important risk factor for HCC is chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection [4].

Patatin-like phospholipase 3 (PNPLA3), alternatively referred to as adiponutrin, encodes a 481-amino acid protein of unknown function that belongs to the patatin-like phospholipase domain-containing family [5].

Adiponutrin (PNPLA3) is a predominantly liver-expressed transmembrane protein that is regulated by fasting and feeding. Recent studies identified PNPLA3 to be associated with hepatic fat content and liver function, thus pointing to a possible involvement in the hepatic lipoprotein metabolism [6].

The PNPLA3 rs738409 C>G nonsynonymous single nucleotide polymorphism creates an Ile148Met change in the adiponutrin protein. This mutation was suggested to impair triglyceride hydrolysis in hepatocytes and favor the increase of triglycerides accumulation [7].


  Subjects and Methods Top


This study was carried out at the Clinical Pathology Department, Faculty of Medicine, Menoufia University, and Clinical Biochemistry Department, National Liver Institute, Menoufia University, from January 2014 to March 2016. The ethical committees of the Faculty of Medicine and the National Liver Institute approved the study protocol. All the patients and controls signed an informed consent before participation in the study.

This study included 50 individuals – 41 men and nine women, their ages ranging from 30 to 53 years – divided into three groups: group 1 (control group) included 10 apparently healthy age and sex-matched subjects (eight men and two women), their ages ranging from 37 to 53 years; group 2 (cirrhosis group) included 20 patients with cirrhosis and positive anti-HCV antibodies (15 men and five women), their ages ranging from 30 to 52 years; and group 3 (HCC group) included 20 HCC patients (18 men and two women), their ages ranging from 35 to 51 years.

All patients enrolled in this study were nonsmokers and negative for HBV and HIV. Furthermore, patients with either a history of autoimmune diseases, diabetes mellitus, schistosomiasis, or having BMI greater than 35 or cirrhosis due to causes other than HCV were excluded from the study.

All the participants were subjected to the following: full history taking, complete clinical examination, abdominal ultrasound and/or computed tomography, liver biopsy (for some cases), and laboratory investigations including complete blood count, liver function tests, viral markers, serum α-feto protein (AFP), and genotyping of PNPLA3 rs738409C/G polymorphism by PCR-RFLP.

Samples collection

Venous blood samples of 10 ml each were collected from all participants by venipuncture from the cubital vein, and were collected as follows: 4 ml collected into EDTA-containing tubes, for complete blood count and genotyping of PNPLA3 gene; 2 ml collected into a citrated tube for prothrombin time and concentration; and the remaining 4 ml in a plain vacutainer tube. The samples were kept for 15 min for coagulation, then centrifuged at 3000 rpm for 10 min, after which the sera were separated into aliquots for liver function tests, viral markers (hepatitis B surface antigen, anti-HCV-antibody), and AFP.

Assay methods

PNPLA3 rs738409C/G gene polymorphism was genotyped using a polymerase chain reaction-based restriction fragment length polymorphism assay. Genomic DNA was extracted from whole-blood samples by means of the QIAamp DNA blood mini kit (Qiagen, Milan, Italy) according to the manufacturer's instruction. A 157 bp product was obtained with the forward primer 5'-TACCACGCCTCTGAAGGAAG-3' and the reverse primer 5'-CCCTGCTCACTTGGAGAAAG -3'. PCR amplification was carried out in a total volume of 50 μl containing 25 μl of a ready for use master mix, 1.0 μl of forward primer, 1.0 μl of reverse primer, 5 μl of template DNA, and 18 μl of RNase-free water.

The thermal cycler was programmed for the following conditions: initial denaturation at 94°C for 3 min and 40 cycles of amplification consisting of denaturation at 95°C for 30 s, annealing at 58°C for 30 s, and extension at 72°C for 30 s. After the last cycle, a final extension of 10 min at 72°C was carried out.

In a total volume of 50, 10 μl of the amplicons were digested with 5U of the fast digest Fok-I restriction endonuclease (New England Biolabs) at 37°C for 1 h. The fragments digested were 99 + 58 bp (Ipswich, MA, UK) for the G allele and 157 bp for the C allele, respectively. The fragments were resolved through electrophoresis in a 3.5% agarose gel after staining with ethidium bromide [Figure 1] and [Figure 2].
Figure 1: Patatin-like phospholipase 3 gene after amplification bands that correspond to ladder band size of 157 bp (lane 2–7), lane (1 and 8) 50 bp DNA ladder.

Click here to view
Figure 2: The products of patatin-like phospholipase 3 gene after digestion by FOK-I restriction enzyme on gel electrophoresis. Lane (8): 50 bp ladder; lane (4 and 7): CC genotype (157 bp); lane (2, 3 and 6): CG genotype (57, 99 and 157 bp); lane (1 and 5): GG genotype (57 and 99 bp).

Click here to view


Statistical analysis

The data collected were tabulated and analyzed (SPSS, Chicago, Illinois, USA) by using the statistical package for the social science software, version 20 on an IBM compatible computer. A P value of less than 0.05 was considered statistically significant.


  Results Top


There was a statistically significant difference between the control group and the cirrhosis group regarding all the studied parameters with a significant increase in alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), γ-glutamyltransferase (GGT), total bilirubin (T.bil), international normalized ratio (INR), and AFP in the cirrhosis group compared with the control group. On the other hand, there was a significant decrease in total protein (TP), albumin (Alb), and platelets in the cirrhosis group compared with the control group [Table 1].
Table 1: Statistical comparison between the control and the cirrhosis group regarding studied laboratory variables

Click here to view


There was a statistically significant difference between the control group and the HCC group regarding all the studied parameters, with a significant increase in ALT, AST, ALP, GGT, T.bil, INR, and AFP in the HCC group compared with the control group. Whereas there was a significant decrease in TP, Alb, and platelets in the HCC group compared with the control group

[Table 2].
Table 2: Statistical comparison between the control and the hepatocellular carcinoma group regarding studied laboratory variables

Click here to view


There was a statistically significant difference between the cirrhosis group and the HCC group regarding platelets, ALP, GGT, T. Bil, AFP, and INR. However, there was no statistically significant difference between the cirrhosis group and the HCC group regarding TP, Alb, ALT, and AST [Table 3].
Table 3: Statistical comparison between the cirrhosis and the hepatocellular carcinoma group regarding studied laboratory variables

Click here to view


There were no significant differences in PNPLA3 genotypes and allele distribution between the cirrhotic and the control groups [Table 4].
Table 4: Patatin-like phospholipase 3 genotypes and allele distribution in the control and the cirrhosis group

Click here to view


Statistically significant differences were found in genotype distribution between the control and HCC groups [CG vs. CC: P = 0.01; odds ratio (OR) = 18, 95% confidence interval (CI): 2.04–159.1, GG vs. CC: P = 002]. OR showed that the GG genotype was riskier than the CC 'reference group' by 18 (95% CI: 2.04–159.1). There was a statistically significant difference in the distribution of both alleles (C and G) between the two groups (P = 0.00). Moreover, oOR showed that G allele was riskier than C allele by 18.69 (95% CI: 3.76–92.9) [Table 5].
Table 5: Patatin-like phospholipase 3 genotypes and allele distribution in the control and the hepatocellular carcinoma group

Click here to view


Statistically, there was significant difference in GG genotype distribution between the cirrhosis and HCC groups (GG vs. CC: P = 0.02; OR = 13.5, 95% CI = 1.80–101.1). OR showed that GG genotype was riskier than the CC 'reference group' by 5.06 (95% CI: 0.83–11.02). Statistically, there was significant difference in the distribution of both alleles (C and G) between both groups (P = 0.007). OR showed that G allele was riskier than C allele by 3.86 (95% CI: 1.53–9.75) [Table 6].
Table 6: Patatin-like phospholipase 3 genotypes and allele distribution in the cirrhosis and the hepatocellular carcinoma group

Click here to view



  Discussion Top


HCV infection is a frequent cause of acute and chronic hepatitis, and leads to the development of cirrhosis and HCC [8].

HCC, also called malignant hepatoma, is the most common type of primary liver cancer, accounting for 70–85% of the total liver cancer burden worldwide. It is the carcinoma of the liver derived from well-differentiated hepatocytes [9].

This study aimed to verify whether the rs738409C/G single nucleotide polymorphism of PNPLA3 was associated with cirrhosis and HCC complicating cirrhosis.

In the present study, the mean age of HCC patients was 44.75 ± 4.23 years. This was in agreement with a study by Sherman [10], who stated that the incidence of HCC starts to increase after 45 years of age. Similarly, Bosch et al. [11] reported that the incidence of liver cancer increases after 20 years of age and peaks at about age 50.

The present study showed that HCC was more predominant in men than in women. This finding was in agreement with the findings of the most recent World Health report (WHO) that indicated a total of 714 600 new cases of HCC worldwide, with 71% among them being men. In their respective studies, Yeh and Chen [12], Kuske et al. [13], and EL-Serag [14] have also reported that male sex is an important risk factor for HCC. This could be explained by the higher rate of exposure to risk factors. Men are more frequently infected with HCV and HBV, smoke cigarettes, and have a high iron stores and carcinogenic substances. In addition, sex hormones and other X-linked genetic factors may also be important [15].

In the current study, platelet count, TP, and Alb were significantly lower in both cirrhotic and HCC patients compared with controls. This was in agreement with França et al. [16], who reported that there were various theories about thrombocytopenia in chronic liver diseases. These theories included decreased thrombopoietin levels, splenic sequestration of platelets due to portal hypertension, autoantibody destruction of platelets, and bone marrow suppression due to underlying liver disease.

Dufour et al. [17] stated that serum Alb is an excellent marker of hepatic synthetic function in patients with chronic liver disease and cirrhosis. A low serum Alb indicates poor liver function.

In the present study, the liver biochemical profile (ALT, AST, GGT, and ALP and T.bil) were significantly higher in both cirrhotic and HCC patients compared with controls. These findings were in agreement with those of Thapa and Walia [18], who declared that aminotransferases are the most frequently utilized indicators of hepatocellular necrosis and expected to be elevated in liver cell injury whatever the cause and that the conventional tests of hepatic function do not distinguish HCC from cirrhosis and thus contribute little to the diagnosis of the tumor. Moreover, serum ALP, GGT, and T.bil were significantly elevated in the HCC group compared with the cirrhosis group because of the more prominent cholestatic effect of the tumor.

In the current study, GGT levels were highly significant in the HCC group than in the cirrhosis group. This was in agreement with the findings by Carr et al. [19] who noted the same elevation of GGT levels. Moreover, they noted the presence of HCC-specific isoenzymes of γ-glutamyl transpeptidase. The biological significance of elevated GGT for the growth of HCC is not yet clear. It is a membrane-bound enzyme that catalyzes the degradation of glutathione and other γ-glutamyl compounds by hydrolysis of the γ-glutamyl moiety or by its transfer to an acceptor. GGT expression is highest in embryo livers and decreases rapidly to its lowest levels after birth, but then increases again during HCC development. The overexpression of GGT in HCC may thus be related to several possible mechanisms, including the hypomethylation status of CCGG sites of GGT genes [20].

These findings were also in line with those of Esaki et al. [21], as they reported a significant increase of ALT, AST, ALP, GGT, and T.bil in HCC patients. Similarly, Żwirska-Korczala et al. [22] observed that serum levels of ALT, AST, and T.bil were significantly increased in cirrhotic patients compared with controls.

In the current study there was a significant increase in INR in the patients' groups (HCC and cirrhotic) compared with the control group as a result of a decreased rate of prothrombin synthesis by the injured and exhausted liver cells. This was in agreement with Franca et al. [16]. They explained the decrease in prothrombin concentration and the increase in INR by the decreased production of tissue factor, factor VII, vitamin K-dependent factors, which are synthesized by hepatocytes, and coagulation factors in the common pathway (prothrombin, factors V and X, and fibrinogen).

AFP level in the current study was significantly higher in both cirrhotic and HCC patients compared with controls. The present study also revealed a significantly higher level of AFP in HCC patients compared with cirrhotic patients. This was in agreement with Spadaro et al. [23] and Anwar et al. [24] who reported a significant elevation in serum AFP in the HCC group compared with the cirrhosis and control groups.

The genotyping results of this study showed that the frequency of CC carriers was higher in healthy controls compared with HCC patients (80 vs. 10%). This was consistent with Falleti et al. [25] who reported that the frequency of the CC genotype was higher in healthy controls compared with HCC patients (50.9 vs. 30.4%).

As regards genotyping results, the frequency of GG variant genotype of PNPLA3 (rs738409) in the present study was higher in HCC patients compared with healthy controls (45 vs. 0%). This was in agreement with Falleti et al. [25] who reported that the frequency of the GG genotype was higher in HCC patients compared with healthy controls (27 vs. 8.2%).

Trépo et al. [26] stated that as PNPLA3 (rs738409 C>G) was initially reported to be associated with more pronounced steatosis, advanced fibrosis, and cirrhosis, it was tempting to speculate that this gene might also promote liver carcinogenesis. They also reported a significant association between PNPLA3 (rs738409 C>G) and HCC.

As regards allele distribution in the present study, the results showed that G allele was increased in the HCC group compared with the control group (67.5 vs. 10%), whereas C allele was the predominant allele in the control group compared with the HCC group (90 vs. 32.5%). As regards OR of alleles in the studied groups, G allele was riskier for HCC 18.69 times than C allele with (95% CI: 3.76–92.9). This was consistent with Trépo et al. [26] who stated that a two-fold HCC risk was observed for those bearing the rs738409[G] allele.

As regards genotyping results, the frequency of GG variant genotype of PNPLA3 (rs738409) in the present study was higher in HCC patients compared with cirrhosis patients (45 vs. 15%). This was consistent with the findings of Falleti et al. [25] who reported that the frequency of the GG genotype was higher in HCC patients compared with cirrhosis patients (27 vs. 19.7%).

Regarding allele distribution in this study, the results showed that G allele was increased in the HCC group compared with the cirrhosis group (67.5 vs. 35%). Regarding OR of alleles of the studied groups, G allele was riskier for the occurrence of HCC on top of cirrhosis 3.86 times than C allele with (95% CI: 1.53–9.75). These results were in agreement with Trépo et al. [26], who stated that PNPLA3 (rs738409 C>G) was associated with the development of HCC among cirrhotic patients whatever the etiology of cirrhosis.


  Conclusion Top


This study revealed that PNPLA3 rs738409 C>G polymorphism was associated with HCC in HCV cirrhotic patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Garcia-Tsao G, Friedman S, Iredale J, Pinzani M. Now there are many (stages) where before there was one: in search of a pathophysiological classification of cirrhosis. Hepatology 2010; 51:1445–1449.  Back to cited text no. 1
    
2.
Thomas MB, Jaffe D, Choti MM, Belghiti J, Curley S, Fong Y, et al. Hepatocellular carcinoma: consensus recommendations of the National Cancer Institute Clinical Trials Planning Meeting. J Clin Oncol 2010; 28:3994–4005.  Back to cited text no. 2
    
3.
El-Said HH, Ghanayem NM, Badr EA, El-Fert AY, Gaballah AK. Cytotoxic T-lymphocyte antigen-4 gene polymorphisms in hepatocellular carcinoma patients in Egypt. Menoufia Med J 2014; 27:372–378.  Back to cited text no. 3
    
4.
Yoshida K. New biomarkers for early detection of hepatocellular carcinoma. EBioMedicine 2015; 2:370–371.  Back to cited text no. 4
    
5.
Mackawy A, Badawi M, Megahed O. Patatin-like phospholipase domain containing-3 gene (PNPLA3) I148M polymorphism and liver damage in chronic hepatitis C Egyptian patients. Egypt J Med Hum Genet 2015; 16:333–341.  Back to cited text no. 5
    
6.
Kollerits B, Coassin S, Beckmann ND, Teumer A, Kiechl S, Döring A, et al. Genetic evidence for a role of adiponutrin in the metabolism of apolipoprotein B-containing lipoproteins. Hum Mol Genet 2009; 18:4669–4676.  Back to cited text no. 6
    
7.
Falleti E, Cussigh A, Cmet S, Fabris C, Toniutto P. PNPLA3 rs738409 and TM6SF2 rs58542926 variants increase the risk of hepatocellular carcinoma in alcoholic cirrhosis. Dig Liver Dis 2016; 48:69–75.  Back to cited text no. 7
    
8.
Negro F, Alaei M Hepatitis C virus and type 2 diabetes. World J Gastroenterol 2009; 15:1537–1547.  Back to cited text no. 8
    
9.
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011; 61:69–90.  Back to cited text no. 9
    
10.
Sherman M. Hepatocellular carcinoma: screening and staging. Clin Liver Dis 2011; 15:323–334.  Back to cited text no. 10
    
11.
Bosch FX, Ribes J, Cléries R, Díaz M. Epidemiology of hepatocellular carcinoma. Clin Liver Dis 2005; 9:191–211.  Back to cited text no. 11
    
12.
Yeh SH, Chen PJ. Gender disparity of hepatocellular carcinoma: the roles of sex hormones. Oncology 2010; 78 (Suppl 1): 172–179.  Back to cited text no. 12
    
13.
Kuske L, Mensen A, Müllhaupt B, Negro F, Semela D, Moradpour D, et al. Characteristics of patients with chronic hepatitis C who develop hepatocellular carcinoma. Swiss Med Wkly 2012; 142:w13651.  Back to cited text no. 13
    
14.
El-Serag HB. Epidemiology of viral hepatitis and hepatocellular carcinoma. Gastroenterology 2012; 142:1264–1273.e1.  Back to cited text no. 14
    
15.
El-Serag HB, Marrero JA, Rudolph L, Reddy KR. Diagnosis and treatment of hepatocellular carcinoma. Gastroenterology 2008; 134:1752–1763.  Back to cited text no. 15
    
16.
França AV, Elias Junior J, Lima BL, Martinelli AL, Carrilho FJ. Diagnosis, staging and treatment of hepatocellular carcinoma. Braz J Med Biol Res 2004; 37:1689–1705.  Back to cited text no. 16
    
17.
Dufour DR, Lott JA, Nolte FS, Gretch DR, Koff RS, Seeff LB. Diagnosis and monitoring of hepatic injury. II. Recommendations for use of laboratory tests in screening, diagnosis, and monitoring. Clin Chem 2000; 46:2050–2068.  Back to cited text no. 17
    
18.
Thapa BR, Walia A. Liver function tests and their interpretation. Indian J Pediatr 2007; 74:663–671.  Back to cited text no. 18
    
19.
Carr BI, Pancoska P, Branch RA. Low alpha-fetoprotein hepatocellular carcinoma. J Gastroenterol Hepatol 2010; 25:1543–1549.  Back to cited text no. 19
    
20.
Yao D, Jiang D, Huang Z, Lu J, Tao Q, Yu Z, et al. Abnormal expression of hepatoma specific gamma-glutamyl transferase and alteration of gamma-glutamyl transferase gene methylation status in patients with hepatocellular carcinoma. Cancer 2000; 88:761–769.  Back to cited text no. 20
    
21.
Esaki T, Suzuki N, Yokoyama K, Iwata K, Irie M, Anan A, et al. Hepatocellular carcinoma in a patient with liver cirrhosis associated with negative serum HCV tests but positive liver tissue HCV RNA. Intern Med 2004; 43:279–282.  Back to cited text no. 21
    
22.
Żwirska-Korczala K, Kukla M, Ziółkowski A, Janczewska-Kazek E, Berdowska A, Sitkiewicz A, et al. Leptin, neopterin and hepatocyte growth factor as markers of fibrosis and inflammatory activity in chronic hepatitis C. Exp Clin Hep 2005; 1:60–65.  Back to cited text no. 22
    
23.
Spadaro A, Ajello A, Morace C, Zirilli A, D'arrigo G, Luigiano C, et al. Serum chromogranin-A in hepatocellular carcinoma: diagnostic utility and limits. World J Gastroenterol 2005; 11:1987–1990.  Back to cited text no. 23
    
24.
Anwar WA, Khaled HM, Amra HA, El-Nezami H, Loffredo CA. Changing pattern of hepatocellular carcinoma (HCC) and its risk factors in Egypt: possibilities for prevention. Mutat Res 2008; 659:176–184.  Back to cited text no. 24
    
25.
Falleti E, Fabris C, Cmet S, Cussigh A, Bitetto D, Fontanini E, et al. PNPLA3 rs738409C/G polymorphism in cirrhosis: relationship with the aetiology of liver disease and hepatocellular carcinoma occurrence. Liver Int 2011; 31:1137–1143.  Back to cited text no. 25
    
26.
Trépo E, Romeo S, Zucman-Rossi J, Nahon P. PNPLA3 gene in liver diseases. J Hepatol 2016; 65:399-412.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Subjects and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed465    
    Printed7    
    Emailed0    
    PDF Downloaded45    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]